“The practice of medicine is an art, not a trade; a calling, not a business…”
– William Osler
Dr. Osler was a great physician and a great man. However, in America today medicine may be a calling and may be partly art, but it is also increasingly part science and, for many physicians in private practice, it must also be part business.
This article will attempt to examine the role of Healthcare Information Technology (HIT), and Electronic Medical Records (EMR or EHR) in particular, in the art, science and business of medicine as practiced today, whether by choice or due to political and economic circumstances in 21st century America.
From the dawn of medicine to the present day, there was always an element of magic and religion associated with healing of the human body and spirit. From the days of Imhotep, to Hippocrates, to Sir William Osler, the practice of medicine had an aura of sanctity and it demanded higher standards from its practitioners. As Bernadine Healy sums it up, the Art of medicine has four principles: Mastery. Individuality. Humanity. Morality.
It is hard to imagine that computers can have any ability to contribute to one’s intrinsic character and intellectual capabilities in a direct way. Maybe it can help with Mastery by augmenting one’s expertise, but there’s very little computers can do to enhance wisdom and creative thinking. I would venture to conclude that the Art portion of medicine is impervious to EHRs of any shape or form.
The Science of medicine is unlike other sciences. Mathematics, physics and chemistry are governed by basic laws and are deterministic in nature. Biology and medicine are observational and largely based on statistical methods with significant margins of error and deviations. The Science of medicine consists of vast amounts of, sometimes conflicting and sometimes inconclusive, evidence. While Euclid’s manuscripts are absolute, Imhotep’s surviving medical manuals are merely interesting and definitely outdated.
Computers are a perfect match for collecting, distilling and presenting the Science of medicine to its practitioners at the point of care. Connected computers can collect vast amounts of data and aggregate it for analysis, giving the medical scientific community powerful tools for creating better evidence. In this context, EHRs should provide three distinct services in the following order. First, they must collect data locally in offices and hospitals. Second, they need to transport the data to where it can be analyzed and learned from. Third, they need to deliver the ever growing medical body of knowledge in a useful format to the practitioner. The provision of these services is constrained by requirements that their enactment should not negatively affect the Business of medicine, nor intrude on the Art.
Today’s EHRs, across the board, are presenting with difficulties in data collection. Either the technology is not there yet, or the user interface is inadequate for data collection without violating the constraints. This is true for the “monolithic legacy EMRs” as well as the newer web based, and somewhat modular offerings. However, anecdotal evidence suggests that some physicians are able to achieve successful data collection and an attempt should be made to research, quantify and learn from this evidence. Perhaps the ONC funding for Beacon projects will do just that.
Data transport is in its infancy. The ONC efforts as embodied by the Meaningful Use criteria and the work of the Standards and Policy committees are great beginnings. Data transport is a purely technical issue and it will be resolved.
Delivering the learned evidence back to the practitioner should be the scientific ROI for data collection (remember the constraints). The current level of Clinical Decision Support (CDS) across established EHRs varies from absolutely nothing, to pharmaceutical alerts, to homemade preventive care/disease management rules, to condition related monographs available in the workflow and even suggestions for assessment and plans. There are vendors specializing in CDS and their offerings are constantly growing and improving. The newest trend is in the analytics area, where various vendors, mostly with payer blessings, provide analysis of mainly claims data to physicians.
The holy grail for delivering useful data back to the physician should be real time, personalized information extracted from every pertinent study ever conducted, presented in a useful, unbiased, and comparative format to the attending physician, the patient and other care givers, both in the workflow and on demand. Just like the current CDS, this would be an example of an independent module that vendors can integrate into their EHRs, and in my opinion, the massive, ever growing, national knowledge base, complete with algorithms, should be provided by the government as a free service.
Once we accomplish these three steps, practicing physicians will have the entire Science of medicine at their fingertips at any given time, for any given patient, and so will the rest of us.
With most humble apologies to Dr. Osler, we must talk now about money. The Business of medicine is most pertinent to those physicians in private practice, but although salaried doctors may seem free of such mundane concerns, somebody at their place of employment is bound to consider financial aspects of health care delivery.
Computers have been employed in business operations for decades and have improved efficiency and profitability for large and small businesses alike. Computers are currently employed by practically all health care delivery systems for the same purpose. Computerized Practice Management Systems (PMS) are used for automation of patient flow management, outreach and of course billing. However, many functionalities of “pure” EHR software should also contribute to business efficiency. Automation of appointment reminders, prescription refills, faxing, filling forms, document management and even CPOE should increase efficiencies and reduce overhead. There is not, and there should not be, a clear separation between the lofty EHR technology and the lowly PMS.
Running a business is a conservative affair. Selecting software to run a business adds a different dimension to selecting technology for a medical enterprise, be it a small practice or a hospital or an Integrated Delivery Network (IDN). Innovation and adherence to the latest Web 2.0 culture is less important than robustness and “tried and true” solid performance and proven longevity of the vendor. And let’s be honest, there really is no point in attempting to manage AR for Mass General on an iPhone, or iPad for that matter. Since technology is never the core competency of a health care organization, turnkey and, yes, monolithic products are a much better fit than a bewildering array of small modules that need to be painstakingly integrated by physicians and/or administrators. Integration is fraught with risk and is expensive, therefore not very good for business.
To use the ubiquitous automobile analogy, would you rather buy a Honda with a built in Bose MP3 surround sound, or would you rather buy a car made by Bose, or would you prefer to install the Bose system in your Honda all by yourself? For small medical businesses and most larger ones too, it is more likely that modular integration will continue to occur at the vendor level, while physicians will continue to look for the simplest and most cost effective comprehensive solution.
As the country at large, and the medical complex in particular, is grappling with challenges to manage health care costs down, the importance of affordable Enterprise quality tools to streamline the Business of medicine will only increase.
The widespread adoption of Information Technology in health care delivery settings is all but inevitable now. And while it is true that much needs to be improved as far as existing EHRs are concerned, it is also true that most vendors are aware of the shortcomings and are feverishly working on innovative solutions either built in-house or integrated from smaller and highly specialized solution providers. The flurry of mergers and acquisitions are a most meaningful telltale sign. Another encouraging phenomenon is the shift from software license purchasing to pay-as-you-go subscription models. For physician practices, there are top of the line EHR and PMS technologies that can be obtained for a few hundred dollars per month, and there are some “free” solutions as well. There are also old vendors still clinging to the Cadillac pricing scheme, but they will have to relent to stay competitive.
While EHRs have been around for decades, it seems that they never managed to cross the chasm from early adopters to widespread use. Some say that it is due to the failed legacy technology, others point to the lack of tangible ROI to the physician. Either way, the recent government initiatives are pushing EHRs over the chasm. As is always the case with technology, from cell phones to email applications, with increased adoption will come better technology and dramatic improvements in quality, from vendors large and small.
In the next few years, the Business of medicine should be almost completely automated and as ONC’s all-out efforts start bearing fruit, the Science of medicine will begin to see a bi-directional flow of information between physicians, repositories of medical knowledge, patients and families. That elusive ROI on data collection will materialize in the form of better patient care and improved outcomes.
As to the last vestiges of magic, the Art of medicine, the best it can hope for is that EHRs will not interfere too much with the patient doctor relationship, or with the art of listening and taking histories, or with the creativity and wisdom of seeing beyond the obvious.
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I believe this is all cyclical. Someday we may be able to practice medicine ethically and be businesspeople?
But that time is not now.
We have ruined our profession by the excesses of the business model
Dr. Rick Lippin
On one hand I am tempted to agree with both Dr. Lippin and Wendell. On the other hand, maybe there’s a way to ethically combine business and medicine. This is purely anecdotal, but I know several physicians who are extremely savvy businessmen and at the same time, most compassionate and honest doctors.
I don’t know how we got here, but nowadays “business” almost automatically implies dishonesty and profiteering. But is it necessarily so? There are honest business people out there, who insist on making a living practicing their art or answering to an inner calling. Some of them are writers, actors, painters, programmers, lawyers (yes, lawyers) and some could be doctors.
Is this not possible anymore?
As usual, excellent commentary from Margalit.
I agree with Dr. Lippin. I personally dislike cat/dog analogies, but the cliche about “herding cats” is applicable to physicians and perhaps an apt analogy.
The resistance from physicians to a clearly valuable technological tool such as a good-quality EMR system reflects a puzzling and grossly counterproductive behavioral attitude among far too many physicians.
In addition that physicians in any size of ambulatory environment should play the role of medical specialist and small business person at the same time is no doubt one of several reasons why the medical services profession/business wastes so many resources.
The “business of medicine” at the provider level is an oxymoron.
All physicians need to be on a good salary. If they don’t like being a salaried professional let them quit and enter the business world. Those who took their MBAs – trade them in for degrees in ethics or theology.
Outside of providers the business of medicine which is real needs to more carefully regulated.
No bio-medical technology, much of which is truly miraculous, including EHRs will ever replace the art of medicine.
While this post provides some good historical perspective, how we strayed so far from professionalism in US Medicine remains an enigma to me?
My only possible partial explanation is that we are a very young and very immature nation.
Dr. Rick Lippin